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As Zika looms, are LARCs the answer?
In U.S. states where mosquito-borne Zika virus transmission is possible, adult women at risk for unintended pregnancy and sexually active high school girls are primarily using moderately effective and less effective contraceptive methods, according to a report from the Centers for Disease Control & Prevention.
Long-acting reversible contraceptives (LARCs) – considered a highly effective method – are used by fewer than a quarter of nonpregnant women, about one-third of recently postpartum women, and fewer than one-tenth of sexually active high school girls, according to a report published Aug. 2 in the Morbidity and Mortality Weekly Report (doi: 10.15585/mmwr.mm6530e2).
With locally transmitted cases of Zika virus infection increasing rapidly in Florida, the CDC is urging that the full range of FDA-approved contraceptive methods should be readily available and accessible to women who want to avoid or delay pregnancy.
“Given low rates of LARC use, states can implement strategies to remove barriers to the access and availability of LARC including high device costs, limited provider reimbursement, lack of training for providers serving women and adolescents on insertion and removal of LARC, provider lack of knowledge and misperceptions about LARC, limited availability of youth-friendly services that address adolescent confidentiality concerns, inadequate client-centered counseling, and low consumer awareness of the range of contraceptive methods available,” the CDC scientists wrote in the MMWR report.
Among nonpregnant women and recently postpartum women, the proportion not using any contraception ranged from 3.5% to 34.3%. Among sexually active high school girls, the proportion using no contraception ranged from 7.3% to 22.8%. The estimates of contraceptive use are based on 2011-2013 and 2015 survey data from four state-based surveillance systems.
The full MMWR report is available here.
On Twitter @maryellenny
In U.S. states where mosquito-borne Zika virus transmission is possible, adult women at risk for unintended pregnancy and sexually active high school girls are primarily using moderately effective and less effective contraceptive methods, according to a report from the Centers for Disease Control & Prevention.
Long-acting reversible contraceptives (LARCs) – considered a highly effective method – are used by fewer than a quarter of nonpregnant women, about one-third of recently postpartum women, and fewer than one-tenth of sexually active high school girls, according to a report published Aug. 2 in the Morbidity and Mortality Weekly Report (doi: 10.15585/mmwr.mm6530e2).
With locally transmitted cases of Zika virus infection increasing rapidly in Florida, the CDC is urging that the full range of FDA-approved contraceptive methods should be readily available and accessible to women who want to avoid or delay pregnancy.
“Given low rates of LARC use, states can implement strategies to remove barriers to the access and availability of LARC including high device costs, limited provider reimbursement, lack of training for providers serving women and adolescents on insertion and removal of LARC, provider lack of knowledge and misperceptions about LARC, limited availability of youth-friendly services that address adolescent confidentiality concerns, inadequate client-centered counseling, and low consumer awareness of the range of contraceptive methods available,” the CDC scientists wrote in the MMWR report.
Among nonpregnant women and recently postpartum women, the proportion not using any contraception ranged from 3.5% to 34.3%. Among sexually active high school girls, the proportion using no contraception ranged from 7.3% to 22.8%. The estimates of contraceptive use are based on 2011-2013 and 2015 survey data from four state-based surveillance systems.
The full MMWR report is available here.
On Twitter @maryellenny
In U.S. states where mosquito-borne Zika virus transmission is possible, adult women at risk for unintended pregnancy and sexually active high school girls are primarily using moderately effective and less effective contraceptive methods, according to a report from the Centers for Disease Control & Prevention.
Long-acting reversible contraceptives (LARCs) – considered a highly effective method – are used by fewer than a quarter of nonpregnant women, about one-third of recently postpartum women, and fewer than one-tenth of sexually active high school girls, according to a report published Aug. 2 in the Morbidity and Mortality Weekly Report (doi: 10.15585/mmwr.mm6530e2).
With locally transmitted cases of Zika virus infection increasing rapidly in Florida, the CDC is urging that the full range of FDA-approved contraceptive methods should be readily available and accessible to women who want to avoid or delay pregnancy.
“Given low rates of LARC use, states can implement strategies to remove barriers to the access and availability of LARC including high device costs, limited provider reimbursement, lack of training for providers serving women and adolescents on insertion and removal of LARC, provider lack of knowledge and misperceptions about LARC, limited availability of youth-friendly services that address adolescent confidentiality concerns, inadequate client-centered counseling, and low consumer awareness of the range of contraceptive methods available,” the CDC scientists wrote in the MMWR report.
Among nonpregnant women and recently postpartum women, the proportion not using any contraception ranged from 3.5% to 34.3%. Among sexually active high school girls, the proportion using no contraception ranged from 7.3% to 22.8%. The estimates of contraceptive use are based on 2011-2013 and 2015 survey data from four state-based surveillance systems.
The full MMWR report is available here.
On Twitter @maryellenny
FROM MMWR
CDC warns pregnant women to avoid Miami neighborhood due to Zika risk
Health officials in Florida have identified 10 new cases of locally transmitted Zika virus infections in the neighborhood just north of downtown Miami where four other cases were reported earlier.
Persistent mosquito populations in southern Florida are the leading cause of the disease’s growing incursion into the continental United States, according to Tom Frieden, MD, MPH, director of the Centers for Disease Control and Prevention.
“This suggests that there is a risk of continued, active transmission of Zika in that area,” Dr. Frieden said Aug. 1 during a press call regarding the discovery of new cases by Florida officials.
The CDC is issuing new recommendations for people who either have visited, are currently visiting, or plan to visit this Miami neighborhood at any point after June 15, the earliest known date on which the infected individuals could have been exposed to the virus.
Women who are pregnant or planning to become pregnant are advised to stay away from the neighborhood north of downtown Miami. Women who live in or around Miami, and who either are or plan to become pregnant, should take steps to protect themselves from mosquitoes. Individuals living in Miami should take precautions to prevent transmitting the disease sexually.
Additionally, the CDC is sending an Emergency Response Team to Florida to assist with efforts to quell the mosquito population and spread awareness about Zika virus prevention.
“These experts include individuals with extensive experience in Zika, in addressing pregnancy and birth defects, in mosquito control, in laboratory science, and community engagement,” Dr. Frieden said.
Dr. Frieden reiterated that controlling the local mosquito population is one of the most effective ways to stop ongoing Zika virus transmission. However, current efforts are being hampered by several factors, including small bodies of standing water near which mosquitoes are breeding, the inherent difficulty in killing this species of mosquito, and the possibility that the Aedes aegypti mosquito is resistant to the insecticides being used.
Vector control experts will work with health officials on the ground in Miami to conduct resistance testing on local mosquitoes, in order to confirm whether the insecticides are working. These tests could be done after just 1 week, but may take 3 or more weeks. Further discussion is also ongoing to determine other ways of bringing down the mosquito population.
“What we know about Zika is scary [but] in some ways, what we don’t know about Zika is even more unsettling,” said Dr. Frieden, who added that “at CDC, more than 1,600 of our experts have been working since January to learn more about Zika and protect the health of pregnant women and others.”
Health officials in Florida have identified 10 new cases of locally transmitted Zika virus infections in the neighborhood just north of downtown Miami where four other cases were reported earlier.
Persistent mosquito populations in southern Florida are the leading cause of the disease’s growing incursion into the continental United States, according to Tom Frieden, MD, MPH, director of the Centers for Disease Control and Prevention.
“This suggests that there is a risk of continued, active transmission of Zika in that area,” Dr. Frieden said Aug. 1 during a press call regarding the discovery of new cases by Florida officials.
The CDC is issuing new recommendations for people who either have visited, are currently visiting, or plan to visit this Miami neighborhood at any point after June 15, the earliest known date on which the infected individuals could have been exposed to the virus.
Women who are pregnant or planning to become pregnant are advised to stay away from the neighborhood north of downtown Miami. Women who live in or around Miami, and who either are or plan to become pregnant, should take steps to protect themselves from mosquitoes. Individuals living in Miami should take precautions to prevent transmitting the disease sexually.
Additionally, the CDC is sending an Emergency Response Team to Florida to assist with efforts to quell the mosquito population and spread awareness about Zika virus prevention.
“These experts include individuals with extensive experience in Zika, in addressing pregnancy and birth defects, in mosquito control, in laboratory science, and community engagement,” Dr. Frieden said.
Dr. Frieden reiterated that controlling the local mosquito population is one of the most effective ways to stop ongoing Zika virus transmission. However, current efforts are being hampered by several factors, including small bodies of standing water near which mosquitoes are breeding, the inherent difficulty in killing this species of mosquito, and the possibility that the Aedes aegypti mosquito is resistant to the insecticides being used.
Vector control experts will work with health officials on the ground in Miami to conduct resistance testing on local mosquitoes, in order to confirm whether the insecticides are working. These tests could be done after just 1 week, but may take 3 or more weeks. Further discussion is also ongoing to determine other ways of bringing down the mosquito population.
“What we know about Zika is scary [but] in some ways, what we don’t know about Zika is even more unsettling,” said Dr. Frieden, who added that “at CDC, more than 1,600 of our experts have been working since January to learn more about Zika and protect the health of pregnant women and others.”
Health officials in Florida have identified 10 new cases of locally transmitted Zika virus infections in the neighborhood just north of downtown Miami where four other cases were reported earlier.
Persistent mosquito populations in southern Florida are the leading cause of the disease’s growing incursion into the continental United States, according to Tom Frieden, MD, MPH, director of the Centers for Disease Control and Prevention.
“This suggests that there is a risk of continued, active transmission of Zika in that area,” Dr. Frieden said Aug. 1 during a press call regarding the discovery of new cases by Florida officials.
The CDC is issuing new recommendations for people who either have visited, are currently visiting, or plan to visit this Miami neighborhood at any point after June 15, the earliest known date on which the infected individuals could have been exposed to the virus.
Women who are pregnant or planning to become pregnant are advised to stay away from the neighborhood north of downtown Miami. Women who live in or around Miami, and who either are or plan to become pregnant, should take steps to protect themselves from mosquitoes. Individuals living in Miami should take precautions to prevent transmitting the disease sexually.
Additionally, the CDC is sending an Emergency Response Team to Florida to assist with efforts to quell the mosquito population and spread awareness about Zika virus prevention.
“These experts include individuals with extensive experience in Zika, in addressing pregnancy and birth defects, in mosquito control, in laboratory science, and community engagement,” Dr. Frieden said.
Dr. Frieden reiterated that controlling the local mosquito population is one of the most effective ways to stop ongoing Zika virus transmission. However, current efforts are being hampered by several factors, including small bodies of standing water near which mosquitoes are breeding, the inherent difficulty in killing this species of mosquito, and the possibility that the Aedes aegypti mosquito is resistant to the insecticides being used.
Vector control experts will work with health officials on the ground in Miami to conduct resistance testing on local mosquitoes, in order to confirm whether the insecticides are working. These tests could be done after just 1 week, but may take 3 or more weeks. Further discussion is also ongoing to determine other ways of bringing down the mosquito population.
“What we know about Zika is scary [but] in some ways, what we don’t know about Zika is even more unsettling,” said Dr. Frieden, who added that “at CDC, more than 1,600 of our experts have been working since January to learn more about Zika and protect the health of pregnant women and others.”
CDC confirms first cases of locally transmitted Zika in continental U.S.
Four cases of Zika virus infection in Florida have been confirmed as the first cases of local transmission of the Zika virus in the continental United States, the Centers for Disease Control and Prevention announced.
“As we have anticipated, Zika is now here,” CDC Director Tom Frieden, MD, MPH, said during a conference call with the media. “These cases are not unexpected [as] we’ve been saying for months, based on our experiences with chikungunya virus and dengue – which are viruses spread by the same mosquitoes that spread Zika – that individual cases and potentially small clusters of Zika are possible in the U.S.”
The cases in question occurred within several blocks of each other in Miami. The individuals were infected in early July, became symptomatic within a few days, and were diagnosed a few days later. Frieden explained that the CDC is proceeding as though these are confirmed cases of local mosquito-borne transmission, which he emphasized is not the same as simply confirming that a person has Zika virus infection.
“We’ve been working closely with Florida and we’ve been impressed by the comprehensiveness of their investigation,” Dr. Frieden said.
Since these cases became diagnosed, Florida officials have implemented “aggressive” mosquito control protocols, which include trying to significantly reduce the local mosquito population by spraying both adult and larval mosquitoes. Dr. Frieden reiterated that killing mosquitoes is one of the most effective ways to ensure local transmission does not occur. Screening of travelers coming into Florida has also been ramped up. Teams are also going door-to-door to eliminate any standing water that may be harboring mosquitoes.
“We’re coordinating closely with Florida, and will continue to support their efforts to assess the situation on a daily basis,” he said.
To reduce the chances of an individual contracting the virus through mosquitos, the CDC continues recommending mosquito repellent; wearing clothing that covers as much of the body as possible; avoiding any areas with still water; and staying in rooms that have air conditioning, fans, or mosquito nets.
“We have been working with state and local governments to prepare for the likelihood of local mosquito-borne Zika virus transmission in the continental United States and Hawaii,” said Lyle R. Petersen, MD, MPH, Director of the CDC’s Division of Vector-Borne Diseases and Incident Manager for the CDC’s Zika Response efforts, in a statement. “We anticipate that there may be additional cases of ‘homegrown’ Zika in the coming weeks. Our top priority is to protect pregnant women from the potentially devastating harm caused by Zika.”
To combat the growing domestic Zika burden, the American Public Health Association called on Congress to allocate more funding, saying that the lack of Congressional support is directly leading to the disease’s incursion into the United States.
“Sadly, we knew this outcome was probable with each passing day that Congress failed to fund Zika protection and response [and] now Congress has adjourned for summer recess.” said Georges C. Benjamin, MD, Executive Director of the APHA, adding that “when Congress comes back in September, it must make sending bipartisan Zika legislation to the president a top priority.”
The American Medical Association echoed that position. “This should be a wake up call to Congress and the Administration that they must resolve their differences and immediately make the necessary resources available for our country to combat the growing threat of the virus,” Andrew W. Gurman, MD, AMA President, said in a statement.
The announcement of locally transmitted Zika virus cases in the continental U.S. comes on the heels of the CDC’s latest Morbidity and Mortality Weekly Report, which found that cases of Zika virus have increased dramatically in Puerto Rico. There have been 5,582 individuals diagnosed with Zika virus so far in 2016, as of July 7. That figure includes 672 pregnant women, with the rate of positive tests increasing from just 14% in February to 64% in June, according to the MMWR (doi: 10.15585/mmwr.mm6530e1).
“Puerto Rico is in the midst of a Zika epidemic. The virus is silently and rapidly spreading in Puerto Rico,” Dr. Peterson said in a separate statement. “This could lead to hundreds of infants being born with microcephaly or other birth defects in the coming year. We must do all we can to protect pregnant women from Zika and to prepare to care for infants born with microcephaly.”
Four cases of Zika virus infection in Florida have been confirmed as the first cases of local transmission of the Zika virus in the continental United States, the Centers for Disease Control and Prevention announced.
“As we have anticipated, Zika is now here,” CDC Director Tom Frieden, MD, MPH, said during a conference call with the media. “These cases are not unexpected [as] we’ve been saying for months, based on our experiences with chikungunya virus and dengue – which are viruses spread by the same mosquitoes that spread Zika – that individual cases and potentially small clusters of Zika are possible in the U.S.”
The cases in question occurred within several blocks of each other in Miami. The individuals were infected in early July, became symptomatic within a few days, and were diagnosed a few days later. Frieden explained that the CDC is proceeding as though these are confirmed cases of local mosquito-borne transmission, which he emphasized is not the same as simply confirming that a person has Zika virus infection.
“We’ve been working closely with Florida and we’ve been impressed by the comprehensiveness of their investigation,” Dr. Frieden said.
Since these cases became diagnosed, Florida officials have implemented “aggressive” mosquito control protocols, which include trying to significantly reduce the local mosquito population by spraying both adult and larval mosquitoes. Dr. Frieden reiterated that killing mosquitoes is one of the most effective ways to ensure local transmission does not occur. Screening of travelers coming into Florida has also been ramped up. Teams are also going door-to-door to eliminate any standing water that may be harboring mosquitoes.
“We’re coordinating closely with Florida, and will continue to support their efforts to assess the situation on a daily basis,” he said.
To reduce the chances of an individual contracting the virus through mosquitos, the CDC continues recommending mosquito repellent; wearing clothing that covers as much of the body as possible; avoiding any areas with still water; and staying in rooms that have air conditioning, fans, or mosquito nets.
“We have been working with state and local governments to prepare for the likelihood of local mosquito-borne Zika virus transmission in the continental United States and Hawaii,” said Lyle R. Petersen, MD, MPH, Director of the CDC’s Division of Vector-Borne Diseases and Incident Manager for the CDC’s Zika Response efforts, in a statement. “We anticipate that there may be additional cases of ‘homegrown’ Zika in the coming weeks. Our top priority is to protect pregnant women from the potentially devastating harm caused by Zika.”
To combat the growing domestic Zika burden, the American Public Health Association called on Congress to allocate more funding, saying that the lack of Congressional support is directly leading to the disease’s incursion into the United States.
“Sadly, we knew this outcome was probable with each passing day that Congress failed to fund Zika protection and response [and] now Congress has adjourned for summer recess.” said Georges C. Benjamin, MD, Executive Director of the APHA, adding that “when Congress comes back in September, it must make sending bipartisan Zika legislation to the president a top priority.”
The American Medical Association echoed that position. “This should be a wake up call to Congress and the Administration that they must resolve their differences and immediately make the necessary resources available for our country to combat the growing threat of the virus,” Andrew W. Gurman, MD, AMA President, said in a statement.
The announcement of locally transmitted Zika virus cases in the continental U.S. comes on the heels of the CDC’s latest Morbidity and Mortality Weekly Report, which found that cases of Zika virus have increased dramatically in Puerto Rico. There have been 5,582 individuals diagnosed with Zika virus so far in 2016, as of July 7. That figure includes 672 pregnant women, with the rate of positive tests increasing from just 14% in February to 64% in June, according to the MMWR (doi: 10.15585/mmwr.mm6530e1).
“Puerto Rico is in the midst of a Zika epidemic. The virus is silently and rapidly spreading in Puerto Rico,” Dr. Peterson said in a separate statement. “This could lead to hundreds of infants being born with microcephaly or other birth defects in the coming year. We must do all we can to protect pregnant women from Zika and to prepare to care for infants born with microcephaly.”
Four cases of Zika virus infection in Florida have been confirmed as the first cases of local transmission of the Zika virus in the continental United States, the Centers for Disease Control and Prevention announced.
“As we have anticipated, Zika is now here,” CDC Director Tom Frieden, MD, MPH, said during a conference call with the media. “These cases are not unexpected [as] we’ve been saying for months, based on our experiences with chikungunya virus and dengue – which are viruses spread by the same mosquitoes that spread Zika – that individual cases and potentially small clusters of Zika are possible in the U.S.”
The cases in question occurred within several blocks of each other in Miami. The individuals were infected in early July, became symptomatic within a few days, and were diagnosed a few days later. Frieden explained that the CDC is proceeding as though these are confirmed cases of local mosquito-borne transmission, which he emphasized is not the same as simply confirming that a person has Zika virus infection.
“We’ve been working closely with Florida and we’ve been impressed by the comprehensiveness of their investigation,” Dr. Frieden said.
Since these cases became diagnosed, Florida officials have implemented “aggressive” mosquito control protocols, which include trying to significantly reduce the local mosquito population by spraying both adult and larval mosquitoes. Dr. Frieden reiterated that killing mosquitoes is one of the most effective ways to ensure local transmission does not occur. Screening of travelers coming into Florida has also been ramped up. Teams are also going door-to-door to eliminate any standing water that may be harboring mosquitoes.
“We’re coordinating closely with Florida, and will continue to support their efforts to assess the situation on a daily basis,” he said.
To reduce the chances of an individual contracting the virus through mosquitos, the CDC continues recommending mosquito repellent; wearing clothing that covers as much of the body as possible; avoiding any areas with still water; and staying in rooms that have air conditioning, fans, or mosquito nets.
“We have been working with state and local governments to prepare for the likelihood of local mosquito-borne Zika virus transmission in the continental United States and Hawaii,” said Lyle R. Petersen, MD, MPH, Director of the CDC’s Division of Vector-Borne Diseases and Incident Manager for the CDC’s Zika Response efforts, in a statement. “We anticipate that there may be additional cases of ‘homegrown’ Zika in the coming weeks. Our top priority is to protect pregnant women from the potentially devastating harm caused by Zika.”
To combat the growing domestic Zika burden, the American Public Health Association called on Congress to allocate more funding, saying that the lack of Congressional support is directly leading to the disease’s incursion into the United States.
“Sadly, we knew this outcome was probable with each passing day that Congress failed to fund Zika protection and response [and] now Congress has adjourned for summer recess.” said Georges C. Benjamin, MD, Executive Director of the APHA, adding that “when Congress comes back in September, it must make sending bipartisan Zika legislation to the president a top priority.”
The American Medical Association echoed that position. “This should be a wake up call to Congress and the Administration that they must resolve their differences and immediately make the necessary resources available for our country to combat the growing threat of the virus,” Andrew W. Gurman, MD, AMA President, said in a statement.
The announcement of locally transmitted Zika virus cases in the continental U.S. comes on the heels of the CDC’s latest Morbidity and Mortality Weekly Report, which found that cases of Zika virus have increased dramatically in Puerto Rico. There have been 5,582 individuals diagnosed with Zika virus so far in 2016, as of July 7. That figure includes 672 pregnant women, with the rate of positive tests increasing from just 14% in February to 64% in June, according to the MMWR (doi: 10.15585/mmwr.mm6530e1).
“Puerto Rico is in the midst of a Zika epidemic. The virus is silently and rapidly spreading in Puerto Rico,” Dr. Peterson said in a separate statement. “This could lead to hundreds of infants being born with microcephaly or other birth defects in the coming year. We must do all we can to protect pregnant women from Zika and to prepare to care for infants born with microcephaly.”
Skin rash in recent traveler? Think dengue fever
BOSTON – Maintain clinical suspicion for dengue fever among individuals with recent travel to endemic areas who present with a rash and other signs and symptoms of infection, an expert advised at the American Academy of Dermatology summer meeting.
Dengue fever accounts for nearly 10% of skin rashes among individuals returning from endemic areas, and related illness can range from mild to fatal, said Jose Dario Martinez, MD, chief of the Internal Medicine Clinic at University Hospital “J.E. Gonzalez,” UANL Monterrey, Mexico.
“This is the most prevalent arthropod-borne virus in the world at this time, and it is a resurgent disease in some countries, like Mexico, Brazil, and Colombia,” he noted.
Worldwide, more than 2.5 billion people are at risk of dengue infection, and between 50 million and 100 million cases occur each year, while about 250,000 to 500,000 cases of dengue hemorrhagic fever occur each year, and about 25,000 related deaths occur.
In 2005, there was a dengue outbreak in Texas, where 25 cases occurred; and in southern Florida, an outbreak of 90 cases was reported in 2009 and 2010. More recently, in 2015, there was an outbreak of 107 cases of locally-acquired dengue on the Big Island, Hawaii (MMWR). But in Mexico, 18,000 new cases occurred in 2015, Dr. Martinez said.
Of the RNA virus serotypes 1-4, type 1 (DENV1) is the most common, and DENV2 and 3 are the most severe, but up to 40% of cases are asymptomatic, he noted, adding that the virus has an incubation period of 2-8 days. When symptoms occur, they are representative of acute febrile illness, and may include headache, high fever, myalgia, arthralgia, retro-orbital pain, and fatigue. A faint, itchy, macular rash commonly occurs at 2-6 days into the illness. According to the World Health Organization, a probable dengue fever case includes acute febrile illness and at least two of either headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, leukopenia, or supportive serology.
“Sometimes the nose bleeds, the gums bleed, and there is bruising in the patient,” Dr. Martinez said. “Most important are retro-orbital pain and hemorrhagic manifestations, but also supportive serology.”
About 1% of patients progress to dengue hemorrhagic fever or dengue shock syndrome during the critical phase (days 4-7) of illness. This is most likely in those with serotypes 2 and 3, but can occur with all serotypes. Warning signs of such severe disease include abdominal pain or tenderness, persistent vomiting, pleural effusion or ascites, and of particular importance – mucosal bleeding, Dr. Martinez said.
By the WHO definition, a diagnosis of dengue hemorrhagic fever requires the presence of fever for at least 2-7 days, hemorrhagic tendencies, thrombocytopenia, and evidence and signs of plasma leakage; dengue shock syndrome requires these, as well as evidence of circulatory failure, such as rapid and weak pulse, narrow pulse pressure, hypotension, and shock.
It is important to maintain clinical suspicion for dengue fever, particularly in anyone who has traveled to an endemic area in the 2 weeks before presentation. Serologic tests are important to detect anti-dengue antibodies. IgG is important, because its presence could suggest recurrent infection and thus the potential for severe disease, Dr. Martinez said. Polymerase chain reaction can be used for detection in the first 4-5 days of infection, and the NS1 rapid test can be positive on the first day, he noted.
The differential diagnosis for dengue fever is broad, and can include chikungunya fever, malaria, leptospirosis, meningococcemia, drug eruption, and Zika fever.
Management of dengue fever includes bed rest, liquids, and mosquito net isolation to prevent re-infection, as more severe disease can occur after re-infection. Acetaminophen can be used for pain relief; aspirin should be avoided due to risk of bleeding, Dr. Martinez said.
Hospitalization and supportive care are required for those with dengue hemorrhagic fever or dengue shock syndrome. Intensive care unit admission may be required.
Of note, a vaccine against dengue fever has shown promise in phase III trials. The vaccine has been approved in Mexico and Brazil, but not yet in the U.S.
Dr Martinez reported having no disclosures.
BOSTON – Maintain clinical suspicion for dengue fever among individuals with recent travel to endemic areas who present with a rash and other signs and symptoms of infection, an expert advised at the American Academy of Dermatology summer meeting.
Dengue fever accounts for nearly 10% of skin rashes among individuals returning from endemic areas, and related illness can range from mild to fatal, said Jose Dario Martinez, MD, chief of the Internal Medicine Clinic at University Hospital “J.E. Gonzalez,” UANL Monterrey, Mexico.
“This is the most prevalent arthropod-borne virus in the world at this time, and it is a resurgent disease in some countries, like Mexico, Brazil, and Colombia,” he noted.
Worldwide, more than 2.5 billion people are at risk of dengue infection, and between 50 million and 100 million cases occur each year, while about 250,000 to 500,000 cases of dengue hemorrhagic fever occur each year, and about 25,000 related deaths occur.
In 2005, there was a dengue outbreak in Texas, where 25 cases occurred; and in southern Florida, an outbreak of 90 cases was reported in 2009 and 2010. More recently, in 2015, there was an outbreak of 107 cases of locally-acquired dengue on the Big Island, Hawaii (MMWR). But in Mexico, 18,000 new cases occurred in 2015, Dr. Martinez said.
Of the RNA virus serotypes 1-4, type 1 (DENV1) is the most common, and DENV2 and 3 are the most severe, but up to 40% of cases are asymptomatic, he noted, adding that the virus has an incubation period of 2-8 days. When symptoms occur, they are representative of acute febrile illness, and may include headache, high fever, myalgia, arthralgia, retro-orbital pain, and fatigue. A faint, itchy, macular rash commonly occurs at 2-6 days into the illness. According to the World Health Organization, a probable dengue fever case includes acute febrile illness and at least two of either headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, leukopenia, or supportive serology.
“Sometimes the nose bleeds, the gums bleed, and there is bruising in the patient,” Dr. Martinez said. “Most important are retro-orbital pain and hemorrhagic manifestations, but also supportive serology.”
About 1% of patients progress to dengue hemorrhagic fever or dengue shock syndrome during the critical phase (days 4-7) of illness. This is most likely in those with serotypes 2 and 3, but can occur with all serotypes. Warning signs of such severe disease include abdominal pain or tenderness, persistent vomiting, pleural effusion or ascites, and of particular importance – mucosal bleeding, Dr. Martinez said.
By the WHO definition, a diagnosis of dengue hemorrhagic fever requires the presence of fever for at least 2-7 days, hemorrhagic tendencies, thrombocytopenia, and evidence and signs of plasma leakage; dengue shock syndrome requires these, as well as evidence of circulatory failure, such as rapid and weak pulse, narrow pulse pressure, hypotension, and shock.
It is important to maintain clinical suspicion for dengue fever, particularly in anyone who has traveled to an endemic area in the 2 weeks before presentation. Serologic tests are important to detect anti-dengue antibodies. IgG is important, because its presence could suggest recurrent infection and thus the potential for severe disease, Dr. Martinez said. Polymerase chain reaction can be used for detection in the first 4-5 days of infection, and the NS1 rapid test can be positive on the first day, he noted.
The differential diagnosis for dengue fever is broad, and can include chikungunya fever, malaria, leptospirosis, meningococcemia, drug eruption, and Zika fever.
Management of dengue fever includes bed rest, liquids, and mosquito net isolation to prevent re-infection, as more severe disease can occur after re-infection. Acetaminophen can be used for pain relief; aspirin should be avoided due to risk of bleeding, Dr. Martinez said.
Hospitalization and supportive care are required for those with dengue hemorrhagic fever or dengue shock syndrome. Intensive care unit admission may be required.
Of note, a vaccine against dengue fever has shown promise in phase III trials. The vaccine has been approved in Mexico and Brazil, but not yet in the U.S.
Dr Martinez reported having no disclosures.
BOSTON – Maintain clinical suspicion for dengue fever among individuals with recent travel to endemic areas who present with a rash and other signs and symptoms of infection, an expert advised at the American Academy of Dermatology summer meeting.
Dengue fever accounts for nearly 10% of skin rashes among individuals returning from endemic areas, and related illness can range from mild to fatal, said Jose Dario Martinez, MD, chief of the Internal Medicine Clinic at University Hospital “J.E. Gonzalez,” UANL Monterrey, Mexico.
“This is the most prevalent arthropod-borne virus in the world at this time, and it is a resurgent disease in some countries, like Mexico, Brazil, and Colombia,” he noted.
Worldwide, more than 2.5 billion people are at risk of dengue infection, and between 50 million and 100 million cases occur each year, while about 250,000 to 500,000 cases of dengue hemorrhagic fever occur each year, and about 25,000 related deaths occur.
In 2005, there was a dengue outbreak in Texas, where 25 cases occurred; and in southern Florida, an outbreak of 90 cases was reported in 2009 and 2010. More recently, in 2015, there was an outbreak of 107 cases of locally-acquired dengue on the Big Island, Hawaii (MMWR). But in Mexico, 18,000 new cases occurred in 2015, Dr. Martinez said.
Of the RNA virus serotypes 1-4, type 1 (DENV1) is the most common, and DENV2 and 3 are the most severe, but up to 40% of cases are asymptomatic, he noted, adding that the virus has an incubation period of 2-8 days. When symptoms occur, they are representative of acute febrile illness, and may include headache, high fever, myalgia, arthralgia, retro-orbital pain, and fatigue. A faint, itchy, macular rash commonly occurs at 2-6 days into the illness. According to the World Health Organization, a probable dengue fever case includes acute febrile illness and at least two of either headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, leukopenia, or supportive serology.
“Sometimes the nose bleeds, the gums bleed, and there is bruising in the patient,” Dr. Martinez said. “Most important are retro-orbital pain and hemorrhagic manifestations, but also supportive serology.”
About 1% of patients progress to dengue hemorrhagic fever or dengue shock syndrome during the critical phase (days 4-7) of illness. This is most likely in those with serotypes 2 and 3, but can occur with all serotypes. Warning signs of such severe disease include abdominal pain or tenderness, persistent vomiting, pleural effusion or ascites, and of particular importance – mucosal bleeding, Dr. Martinez said.
By the WHO definition, a diagnosis of dengue hemorrhagic fever requires the presence of fever for at least 2-7 days, hemorrhagic tendencies, thrombocytopenia, and evidence and signs of plasma leakage; dengue shock syndrome requires these, as well as evidence of circulatory failure, such as rapid and weak pulse, narrow pulse pressure, hypotension, and shock.
It is important to maintain clinical suspicion for dengue fever, particularly in anyone who has traveled to an endemic area in the 2 weeks before presentation. Serologic tests are important to detect anti-dengue antibodies. IgG is important, because its presence could suggest recurrent infection and thus the potential for severe disease, Dr. Martinez said. Polymerase chain reaction can be used for detection in the first 4-5 days of infection, and the NS1 rapid test can be positive on the first day, he noted.
The differential diagnosis for dengue fever is broad, and can include chikungunya fever, malaria, leptospirosis, meningococcemia, drug eruption, and Zika fever.
Management of dengue fever includes bed rest, liquids, and mosquito net isolation to prevent re-infection, as more severe disease can occur after re-infection. Acetaminophen can be used for pain relief; aspirin should be avoided due to risk of bleeding, Dr. Martinez said.
Hospitalization and supportive care are required for those with dengue hemorrhagic fever or dengue shock syndrome. Intensive care unit admission may be required.
Of note, a vaccine against dengue fever has shown promise in phase III trials. The vaccine has been approved in Mexico and Brazil, but not yet in the U.S.
Dr Martinez reported having no disclosures.
EXPERT ANALYSIS FROM THE AAD SUMMER ACADEMY 2016
United States up to 855 cases of Zika in pregnant women
There was one live-born infant with Zika virus–related birth defects and 77 new cases of Zika among pregnant women reported during the week ending July 21, 2016, in the United States, but no additional Zika-related pregnancy losses, according to the Centers for Disease Control and Prevention.
The new cases bring the totals to 13 infants born with birth defects and 855 pregnant women with any laboratory evidence of Zika virus infection. All of the infants with birth defects so far were born in the 50 states and the District of Columbia, which is where six of the seven Zika-related pregnancy losses occurred. There has been only one pregnancy loss in the U.S. territories, but the territories account for almost half (422) of the 855 pregnant women with Zika infection. Of the 77 new infections in pregnant women for the week, 44 occurred in the territories and 33 were in the states, the CDC reported July 28.
The figures for states, territories, and the District of Columbia reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
There was one live-born infant with Zika virus–related birth defects and 77 new cases of Zika among pregnant women reported during the week ending July 21, 2016, in the United States, but no additional Zika-related pregnancy losses, according to the Centers for Disease Control and Prevention.
The new cases bring the totals to 13 infants born with birth defects and 855 pregnant women with any laboratory evidence of Zika virus infection. All of the infants with birth defects so far were born in the 50 states and the District of Columbia, which is where six of the seven Zika-related pregnancy losses occurred. There has been only one pregnancy loss in the U.S. territories, but the territories account for almost half (422) of the 855 pregnant women with Zika infection. Of the 77 new infections in pregnant women for the week, 44 occurred in the territories and 33 were in the states, the CDC reported July 28.
The figures for states, territories, and the District of Columbia reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
There was one live-born infant with Zika virus–related birth defects and 77 new cases of Zika among pregnant women reported during the week ending July 21, 2016, in the United States, but no additional Zika-related pregnancy losses, according to the Centers for Disease Control and Prevention.
The new cases bring the totals to 13 infants born with birth defects and 855 pregnant women with any laboratory evidence of Zika virus infection. All of the infants with birth defects so far were born in the 50 states and the District of Columbia, which is where six of the seven Zika-related pregnancy losses occurred. There has been only one pregnancy loss in the U.S. territories, but the territories account for almost half (422) of the 855 pregnant women with Zika infection. Of the 77 new infections in pregnant women for the week, 44 occurred in the territories and 33 were in the states, the CDC reported July 28.
The figures for states, territories, and the District of Columbia reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
Risk of Zika virus remains low at Olympics
People attending the 2016 Summer Olympic games in Rio de Janeiro stand a low risk of contracting or spreading the Zika virus, says a new report in the Annals of Internal Medicine.
Attendance at the Rio Olympics is estimated to be between 350,000 and 500,000, according to the report – written by Albert I. Ko, MD, of Yale University in New Haven, Conn. and his colleagues – and in the worst-case scenario, the projected likelihood of infection will be between 1 in 56,300 and 1 in 6,200. This means that, at most, 80 people attending the games will contract the Zika virus (95% confidence interval, 63-98), while the lower bound of the estimate is a mere 6 individuals (95% CI, 2-12). Furthermore, only 1-16 individuals (95% CI, 0-4 and 9-24, respectively) of infected individuals are expected to be symptomatic (Ann Intern Med. 2016 Jul 26. doi: 10.7326/M16-1628).
Data from the 2014 FIFA World Cup tournament – which also took place in Brazil – estimates that 53.3% of attendees will come from one of eight countries or regions: United States, Canada, Europe, Oceania, Japan, South Korea, and Israel, all of which are locations where mosquito-borne disease transmission rates are expected to be low. Individuals who contract Zika virus and take it back home with them are expected to number between 3 (95% CI, 0-7) and 37 (95% CI, 25-49), mainly because the Zika virus is only expected to take 9.9 days to naturally clear any infected individual.
“Most of the remaining travelers (30.2% of the total) are expected to return to Latin American countries already experiencing autochthonous ZIKV transmission, contributing 9.0 (0.0 to 29.7) to 116.0 (59.4 to 188.1) additional person-days of viremia,” the report states. “This effect is negligible relative to prevalent infections caused by ongoing transmission in these countries.”
Recently, the U.S. Centers for Disease Control and Prevention also announced that chances of acquiring the Zika virus are low for those attending the 2016 Summer Olympics, and that only individuals from a small number of countries have any real danger of introducing the disease into a previously unaffected and potentially dangerous climate.
Sexual transmission of Zika virus remains a risk, however, the Annals report notes. People are urged to use condoms or abstain from sex during the Olympics in order to mitigate the risk of spreading the disease. Additionally, women who attend the games are best advised to delay getting pregnant for several weeks, if not months, after returning home. Women who are already pregnant should not attend the games, and everyone who attends the Olympics should wear mosquito repellent, long-sleeve shirts and pants, and use either a fan or a mosquito net in their hotel rooms to avoid getting bitten.
Dr. Ko and his coauthors declared no conflicts of interest.
People attending the 2016 Summer Olympic games in Rio de Janeiro stand a low risk of contracting or spreading the Zika virus, says a new report in the Annals of Internal Medicine.
Attendance at the Rio Olympics is estimated to be between 350,000 and 500,000, according to the report – written by Albert I. Ko, MD, of Yale University in New Haven, Conn. and his colleagues – and in the worst-case scenario, the projected likelihood of infection will be between 1 in 56,300 and 1 in 6,200. This means that, at most, 80 people attending the games will contract the Zika virus (95% confidence interval, 63-98), while the lower bound of the estimate is a mere 6 individuals (95% CI, 2-12). Furthermore, only 1-16 individuals (95% CI, 0-4 and 9-24, respectively) of infected individuals are expected to be symptomatic (Ann Intern Med. 2016 Jul 26. doi: 10.7326/M16-1628).
Data from the 2014 FIFA World Cup tournament – which also took place in Brazil – estimates that 53.3% of attendees will come from one of eight countries or regions: United States, Canada, Europe, Oceania, Japan, South Korea, and Israel, all of which are locations where mosquito-borne disease transmission rates are expected to be low. Individuals who contract Zika virus and take it back home with them are expected to number between 3 (95% CI, 0-7) and 37 (95% CI, 25-49), mainly because the Zika virus is only expected to take 9.9 days to naturally clear any infected individual.
“Most of the remaining travelers (30.2% of the total) are expected to return to Latin American countries already experiencing autochthonous ZIKV transmission, contributing 9.0 (0.0 to 29.7) to 116.0 (59.4 to 188.1) additional person-days of viremia,” the report states. “This effect is negligible relative to prevalent infections caused by ongoing transmission in these countries.”
Recently, the U.S. Centers for Disease Control and Prevention also announced that chances of acquiring the Zika virus are low for those attending the 2016 Summer Olympics, and that only individuals from a small number of countries have any real danger of introducing the disease into a previously unaffected and potentially dangerous climate.
Sexual transmission of Zika virus remains a risk, however, the Annals report notes. People are urged to use condoms or abstain from sex during the Olympics in order to mitigate the risk of spreading the disease. Additionally, women who attend the games are best advised to delay getting pregnant for several weeks, if not months, after returning home. Women who are already pregnant should not attend the games, and everyone who attends the Olympics should wear mosquito repellent, long-sleeve shirts and pants, and use either a fan or a mosquito net in their hotel rooms to avoid getting bitten.
Dr. Ko and his coauthors declared no conflicts of interest.
People attending the 2016 Summer Olympic games in Rio de Janeiro stand a low risk of contracting or spreading the Zika virus, says a new report in the Annals of Internal Medicine.
Attendance at the Rio Olympics is estimated to be between 350,000 and 500,000, according to the report – written by Albert I. Ko, MD, of Yale University in New Haven, Conn. and his colleagues – and in the worst-case scenario, the projected likelihood of infection will be between 1 in 56,300 and 1 in 6,200. This means that, at most, 80 people attending the games will contract the Zika virus (95% confidence interval, 63-98), while the lower bound of the estimate is a mere 6 individuals (95% CI, 2-12). Furthermore, only 1-16 individuals (95% CI, 0-4 and 9-24, respectively) of infected individuals are expected to be symptomatic (Ann Intern Med. 2016 Jul 26. doi: 10.7326/M16-1628).
Data from the 2014 FIFA World Cup tournament – which also took place in Brazil – estimates that 53.3% of attendees will come from one of eight countries or regions: United States, Canada, Europe, Oceania, Japan, South Korea, and Israel, all of which are locations where mosquito-borne disease transmission rates are expected to be low. Individuals who contract Zika virus and take it back home with them are expected to number between 3 (95% CI, 0-7) and 37 (95% CI, 25-49), mainly because the Zika virus is only expected to take 9.9 days to naturally clear any infected individual.
“Most of the remaining travelers (30.2% of the total) are expected to return to Latin American countries already experiencing autochthonous ZIKV transmission, contributing 9.0 (0.0 to 29.7) to 116.0 (59.4 to 188.1) additional person-days of viremia,” the report states. “This effect is negligible relative to prevalent infections caused by ongoing transmission in these countries.”
Recently, the U.S. Centers for Disease Control and Prevention also announced that chances of acquiring the Zika virus are low for those attending the 2016 Summer Olympics, and that only individuals from a small number of countries have any real danger of introducing the disease into a previously unaffected and potentially dangerous climate.
Sexual transmission of Zika virus remains a risk, however, the Annals report notes. People are urged to use condoms or abstain from sex during the Olympics in order to mitigate the risk of spreading the disease. Additionally, women who attend the games are best advised to delay getting pregnant for several weeks, if not months, after returning home. Women who are already pregnant should not attend the games, and everyone who attends the Olympics should wear mosquito repellent, long-sleeve shirts and pants, and use either a fan or a mosquito net in their hotel rooms to avoid getting bitten.
Dr. Ko and his coauthors declared no conflicts of interest.
FROM THE ANNALS OF INTERNAL MEDICINE
To cut Zika microcephaly risk, delay pregnancy more than 9 months
Women and couples planning to get pregnant may want to delay that pregnancy more than 9 months if there is an ongoing outbreak of the Zika virus in their area of residence, although that measure alone is not powerful enough to make a significant dent in stopping the Zika virus from spreading.
That is according to a new study in which investigators examined epidemiological data from Colombian Zika virus cases to determine if delaying pregnancies – which has been advised by a number of Central and South American health ministries – would be an effective course of action against the disease and its effects on both pregnant mothers and their fetuses (Ann Intern Med. 2016 Jul 26. doi: 10.7326/M16-0919).
“We developed a data-driven Zika virus transmission model to evaluate the effect of a mass pregnancy delay strategy in which women of reproductive age avoid pregnancy for the recommended duration, at varying degrees of adherence,” wrote Martial L. Ndeffo-Mbah, PhD, of Yale University in New Haven, Conn., and his coauthors.
Cases included were reported to Colombia’s National Institute of Health between Oct. 11, 2015, and May 8, 2016. Investigators classified cases as “suspected cases” of Zika virus infection if the patient presented to a hospital or clinic with “rash, fever (temperature higher than 37.2 degrees C), and at least one of the following symptoms within 5 days of symptom onset that could not be explained by other medical conditions: nonpurulent conjunctivitis or conjunctival hyperemia, arthralgia, myalgia, headache, or malaise.”
Modeling was used to project incidence rates of Zika virus infections, based on a 50% adherence rate to the recommendations.
Among those women who would delay getting pregnant by 6 months or less after possible exposure to Zika virus, prenatal Zika virus infections would decrease by 2%-7%. However, that number would decrease substantially, by 7%-44%, for those who delayed their pregnancy by as much as 9-24 months after exposure.
“Because the incidence peak of the epidemic occurs around 8 months into the outbreak, a strategy to delay pregnancy by more than 9 months, initiated at the onset of the epidemic, would allow women of reproductive age to avoid being pregnant during the incidence peak, when risk for exposure to Zika virus is highest,” Dr. Ndeffo-Mbah and his coauthors noted.
While delaying pregnancy can significantly reduce the risk of birth defects in infants, the authors noted, it won’t have the same effect on reducing the overall spread of Zika virus in an affected region.
“Our results indicate that delays in pregnancy alone will probably be insufficient to curtail Zika-related birth abnormalities,” the authors concluded. “In the absence of a vaccine or therapeutic drugs for Zika virus infection, a combination of mass and individual pregnancy-delay strategies with effective vector-control measures is needed to curtail the spread and burden of the ongoing outbreak in the Americas.”
The National Institutes of Health funded the study. Dr. Ndeffo-Mbah and his coauthors reported no relevant financial disclosures.
Women and couples planning to get pregnant may want to delay that pregnancy more than 9 months if there is an ongoing outbreak of the Zika virus in their area of residence, although that measure alone is not powerful enough to make a significant dent in stopping the Zika virus from spreading.
That is according to a new study in which investigators examined epidemiological data from Colombian Zika virus cases to determine if delaying pregnancies – which has been advised by a number of Central and South American health ministries – would be an effective course of action against the disease and its effects on both pregnant mothers and their fetuses (Ann Intern Med. 2016 Jul 26. doi: 10.7326/M16-0919).
“We developed a data-driven Zika virus transmission model to evaluate the effect of a mass pregnancy delay strategy in which women of reproductive age avoid pregnancy for the recommended duration, at varying degrees of adherence,” wrote Martial L. Ndeffo-Mbah, PhD, of Yale University in New Haven, Conn., and his coauthors.
Cases included were reported to Colombia’s National Institute of Health between Oct. 11, 2015, and May 8, 2016. Investigators classified cases as “suspected cases” of Zika virus infection if the patient presented to a hospital or clinic with “rash, fever (temperature higher than 37.2 degrees C), and at least one of the following symptoms within 5 days of symptom onset that could not be explained by other medical conditions: nonpurulent conjunctivitis or conjunctival hyperemia, arthralgia, myalgia, headache, or malaise.”
Modeling was used to project incidence rates of Zika virus infections, based on a 50% adherence rate to the recommendations.
Among those women who would delay getting pregnant by 6 months or less after possible exposure to Zika virus, prenatal Zika virus infections would decrease by 2%-7%. However, that number would decrease substantially, by 7%-44%, for those who delayed their pregnancy by as much as 9-24 months after exposure.
“Because the incidence peak of the epidemic occurs around 8 months into the outbreak, a strategy to delay pregnancy by more than 9 months, initiated at the onset of the epidemic, would allow women of reproductive age to avoid being pregnant during the incidence peak, when risk for exposure to Zika virus is highest,” Dr. Ndeffo-Mbah and his coauthors noted.
While delaying pregnancy can significantly reduce the risk of birth defects in infants, the authors noted, it won’t have the same effect on reducing the overall spread of Zika virus in an affected region.
“Our results indicate that delays in pregnancy alone will probably be insufficient to curtail Zika-related birth abnormalities,” the authors concluded. “In the absence of a vaccine or therapeutic drugs for Zika virus infection, a combination of mass and individual pregnancy-delay strategies with effective vector-control measures is needed to curtail the spread and burden of the ongoing outbreak in the Americas.”
The National Institutes of Health funded the study. Dr. Ndeffo-Mbah and his coauthors reported no relevant financial disclosures.
Women and couples planning to get pregnant may want to delay that pregnancy more than 9 months if there is an ongoing outbreak of the Zika virus in their area of residence, although that measure alone is not powerful enough to make a significant dent in stopping the Zika virus from spreading.
That is according to a new study in which investigators examined epidemiological data from Colombian Zika virus cases to determine if delaying pregnancies – which has been advised by a number of Central and South American health ministries – would be an effective course of action against the disease and its effects on both pregnant mothers and their fetuses (Ann Intern Med. 2016 Jul 26. doi: 10.7326/M16-0919).
“We developed a data-driven Zika virus transmission model to evaluate the effect of a mass pregnancy delay strategy in which women of reproductive age avoid pregnancy for the recommended duration, at varying degrees of adherence,” wrote Martial L. Ndeffo-Mbah, PhD, of Yale University in New Haven, Conn., and his coauthors.
Cases included were reported to Colombia’s National Institute of Health between Oct. 11, 2015, and May 8, 2016. Investigators classified cases as “suspected cases” of Zika virus infection if the patient presented to a hospital or clinic with “rash, fever (temperature higher than 37.2 degrees C), and at least one of the following symptoms within 5 days of symptom onset that could not be explained by other medical conditions: nonpurulent conjunctivitis or conjunctival hyperemia, arthralgia, myalgia, headache, or malaise.”
Modeling was used to project incidence rates of Zika virus infections, based on a 50% adherence rate to the recommendations.
Among those women who would delay getting pregnant by 6 months or less after possible exposure to Zika virus, prenatal Zika virus infections would decrease by 2%-7%. However, that number would decrease substantially, by 7%-44%, for those who delayed their pregnancy by as much as 9-24 months after exposure.
“Because the incidence peak of the epidemic occurs around 8 months into the outbreak, a strategy to delay pregnancy by more than 9 months, initiated at the onset of the epidemic, would allow women of reproductive age to avoid being pregnant during the incidence peak, when risk for exposure to Zika virus is highest,” Dr. Ndeffo-Mbah and his coauthors noted.
While delaying pregnancy can significantly reduce the risk of birth defects in infants, the authors noted, it won’t have the same effect on reducing the overall spread of Zika virus in an affected region.
“Our results indicate that delays in pregnancy alone will probably be insufficient to curtail Zika-related birth abnormalities,” the authors concluded. “In the absence of a vaccine or therapeutic drugs for Zika virus infection, a combination of mass and individual pregnancy-delay strategies with effective vector-control measures is needed to curtail the spread and burden of the ongoing outbreak in the Americas.”
The National Institutes of Health funded the study. Dr. Ndeffo-Mbah and his coauthors reported no relevant financial disclosures.
FROM THE ANNALS OF INTERNAL MEDICINE
Key clinical point: Delaying pregnancy after a Zika outbreak can reduce the risk of having a child with microcephaly, but it is only a small part in what must be a larger effort to prevent the spread of Zika virus.
Major finding: Pregnancies delayed by 6 months after a local Zika outbreak could decrease prenatal Zika infections 2%-7%, but delaying pregnancies 9-24 months could decrease infections by 17%-44%.
Data source: A vector-borne Zika virus transmission model of data on Colombian Zika virus infections in 2015-2016.
Disclosures: The National Institutes of Health funded the study. Dr. Ndeffo-Mbah and his coauthors reported no relevant financial disclosures.
CDC updates Zika guidance for managing pregnant women
Updated guidelines released by the Centers for Disease Control and Prevention outline how to diagnose suspected cases of Zika virus infection among pregnant women based on how quickly they present with symptoms.
The guidance was updated in light of “the emerging data indicating that Zika virus RNA can be detected for prolonged periods in some pregnant women,” the CDC wrote in the July 25 issue of the Morbidity and Mortality Weekly Report (doi: 10.15585/mmwr.mm6529e1).
All pregnant women should be assessed for Zika virus at each of their prenatal care visits, regardless of their recent travel history or exposure to mosquitoes, by being evaluated for signs and symptoms of infection, such as fever, rash, and arthralgia. From there, management can take one of two directions.
The first direction involves women who are tested within 2 weeks of either symptom onset, or their suspected exposure to the virus. Pregnant women who are asymptomatic and do not live in an area with an ongoing Zika virus outbreak, as well as women who are symptomatic, should have their serum and urine analyzed using a real-time reverse transcription–polymerase chain reaction (rRT-PCR) test. If the result of this test is positive, it should be considered as confirmation that the woman has a “recent Zika virus infection.”
However, if the test results are negative, symptomatic women should undergo immunoglobin M testing for both Zika virus and dengue virus, while asymptomatic women should undergo just Zika virus IgM testing within 2-12 weeks of the possible exposure. In either case, if the tests come back negative, then the patient can be definitively cleared of any recent Zika virus infection. However, if either the Zika virus or dengue virus tests are positive or equivocal, then there is a “presumptive recent Zika virus or dengue virus or Flavivirus infection” in the woman, at which point plaque reduction neutralization testing (PRNT) must be conducted.
The second direction for management involves pregnant women who are initially tested within 2-12 weeks of either symptom onset or suspected exposure to the virus. Asymptomatic women who do not live in an area with active Zika virus transmission, or do live in an area with ongoing Zika virus cases but are already in the first or second trimester of their pregnancy – along with any women who are symptomatic – should have their serum analyzed through IgM testing for both Zika virus and dengue virus.
If both results are negative, then there is no Zika virus infection. If the Zika virus test is negative but the dengue virus test is either positive or equivocal, the woman has a “presumptive dengue virus infection” and should undergo PRNT. If the Zika virus test is either positive or equivocal, then the woman has a “presumptive recent Zika virus or Flavivirus infection,” regardless of the dengue virus IgM result. In the latter case, the next step is to conduct a reflex Zika virus rRT-PCR test on both serum and urine. A negative result on the serum test should be followed by PRNT; a positive result should be taken as proof of a “recent Zika virus infection.”
For any diagnostic chain that ends with a PRNT, the results of that test can be interpreted in one of three ways. If the Zika virus PRNT result is at least 10 and the dengue virus result is less than 10, then there is a recent Zika virus infection. If both the Zika virus and dengue virus PRNT results are 10 or greater, than there is a Flavivirus infection, but the specific one cannot be determined. Finally, if both results are less than 10, then there is no evidence of a recent Zika virus infection.
“For symptomatic and asymptomatic pregnant women with possible Zika virus exposure who seek care [more than] 12 weeks after symptom onset or possible exposure, IgM antibody testing might be considered,” the CDC wrote. “If fetal abnormalities are present, rRT-PCR testing should also be performed on maternal serum and urine [but] a negative IgM antibody test or rRT-PCR result [more than] 12 weeks after symptom onset or possible exposure does not rule out recent Zika virus infection.”
For pregnant women with a diagnosis of a confirmed or presumptive Flavivirus infection, regardless of whether it’s specifically Zika virus or not, the CDC recommends getting serial ultrasounds every 3-4 weeks during pregnancy in order to monitor the fetus’s development, while “decisions regarding amniocentesis should be individualized for each clinical circumstance.” After the child’s birth, rRT-PCR should be conducted on the child’s cord blood and serum; Zika virus and dengue virus IgM are also recommended.
Pregnant women without a diagnosis of either Zika virus or dengue virus should have a prenatal ultrasound; if abnormalities are found in the fetus, CDC recommends that they have a repeat Zika virus rRT-PCR and IgM test and that clinicians base management on corresponding laboratory results. If nothing is found, however, then standard care can resume with ongoing vigilance to avoid Zika virus infections. Women with dengue virus diagnoses should follow the guidance that is currently in place.
“Pregnant women with laboratory evidence of confirmed or possible Zika virus infection who experience a fetal loss or stillbirth should be offered pathology testing for Zika virus infection,” the CDC added. “This testing might provide insight into the etiology of the fetal loss, which could inform a woman’s future pregnancy planning.”
The CDC also issued updated guidance for preventing sexual transmission of Zika virus and that applies to all men and women who have traveled to or reside in areas with active Zika virus transmission and their sex partners (MMWR. ePub: 2016 25 Jul. doi: 10.15585/mmwr.mm6529e2). The CDC advises couples in which a woman is pregnant to use barriers methods or abstain from sex for the duration of the pregnancy. For couples not planning pregnancy and in which there is a male partner with confirmed Zika virus infection or symptoms of infection, the men should use barrier methods or abstain from sex for at least 6 months after the onset of illness. For women with Zika virus infection, they should use barrier protection or abstain from sex for at least 8 weeks after the onset of illness.
Updated guidelines released by the Centers for Disease Control and Prevention outline how to diagnose suspected cases of Zika virus infection among pregnant women based on how quickly they present with symptoms.
The guidance was updated in light of “the emerging data indicating that Zika virus RNA can be detected for prolonged periods in some pregnant women,” the CDC wrote in the July 25 issue of the Morbidity and Mortality Weekly Report (doi: 10.15585/mmwr.mm6529e1).
All pregnant women should be assessed for Zika virus at each of their prenatal care visits, regardless of their recent travel history or exposure to mosquitoes, by being evaluated for signs and symptoms of infection, such as fever, rash, and arthralgia. From there, management can take one of two directions.
The first direction involves women who are tested within 2 weeks of either symptom onset, or their suspected exposure to the virus. Pregnant women who are asymptomatic and do not live in an area with an ongoing Zika virus outbreak, as well as women who are symptomatic, should have their serum and urine analyzed using a real-time reverse transcription–polymerase chain reaction (rRT-PCR) test. If the result of this test is positive, it should be considered as confirmation that the woman has a “recent Zika virus infection.”
However, if the test results are negative, symptomatic women should undergo immunoglobin M testing for both Zika virus and dengue virus, while asymptomatic women should undergo just Zika virus IgM testing within 2-12 weeks of the possible exposure. In either case, if the tests come back negative, then the patient can be definitively cleared of any recent Zika virus infection. However, if either the Zika virus or dengue virus tests are positive or equivocal, then there is a “presumptive recent Zika virus or dengue virus or Flavivirus infection” in the woman, at which point plaque reduction neutralization testing (PRNT) must be conducted.
The second direction for management involves pregnant women who are initially tested within 2-12 weeks of either symptom onset or suspected exposure to the virus. Asymptomatic women who do not live in an area with active Zika virus transmission, or do live in an area with ongoing Zika virus cases but are already in the first or second trimester of their pregnancy – along with any women who are symptomatic – should have their serum analyzed through IgM testing for both Zika virus and dengue virus.
If both results are negative, then there is no Zika virus infection. If the Zika virus test is negative but the dengue virus test is either positive or equivocal, the woman has a “presumptive dengue virus infection” and should undergo PRNT. If the Zika virus test is either positive or equivocal, then the woman has a “presumptive recent Zika virus or Flavivirus infection,” regardless of the dengue virus IgM result. In the latter case, the next step is to conduct a reflex Zika virus rRT-PCR test on both serum and urine. A negative result on the serum test should be followed by PRNT; a positive result should be taken as proof of a “recent Zika virus infection.”
For any diagnostic chain that ends with a PRNT, the results of that test can be interpreted in one of three ways. If the Zika virus PRNT result is at least 10 and the dengue virus result is less than 10, then there is a recent Zika virus infection. If both the Zika virus and dengue virus PRNT results are 10 or greater, than there is a Flavivirus infection, but the specific one cannot be determined. Finally, if both results are less than 10, then there is no evidence of a recent Zika virus infection.
“For symptomatic and asymptomatic pregnant women with possible Zika virus exposure who seek care [more than] 12 weeks after symptom onset or possible exposure, IgM antibody testing might be considered,” the CDC wrote. “If fetal abnormalities are present, rRT-PCR testing should also be performed on maternal serum and urine [but] a negative IgM antibody test or rRT-PCR result [more than] 12 weeks after symptom onset or possible exposure does not rule out recent Zika virus infection.”
For pregnant women with a diagnosis of a confirmed or presumptive Flavivirus infection, regardless of whether it’s specifically Zika virus or not, the CDC recommends getting serial ultrasounds every 3-4 weeks during pregnancy in order to monitor the fetus’s development, while “decisions regarding amniocentesis should be individualized for each clinical circumstance.” After the child’s birth, rRT-PCR should be conducted on the child’s cord blood and serum; Zika virus and dengue virus IgM are also recommended.
Pregnant women without a diagnosis of either Zika virus or dengue virus should have a prenatal ultrasound; if abnormalities are found in the fetus, CDC recommends that they have a repeat Zika virus rRT-PCR and IgM test and that clinicians base management on corresponding laboratory results. If nothing is found, however, then standard care can resume with ongoing vigilance to avoid Zika virus infections. Women with dengue virus diagnoses should follow the guidance that is currently in place.
“Pregnant women with laboratory evidence of confirmed or possible Zika virus infection who experience a fetal loss or stillbirth should be offered pathology testing for Zika virus infection,” the CDC added. “This testing might provide insight into the etiology of the fetal loss, which could inform a woman’s future pregnancy planning.”
The CDC also issued updated guidance for preventing sexual transmission of Zika virus and that applies to all men and women who have traveled to or reside in areas with active Zika virus transmission and their sex partners (MMWR. ePub: 2016 25 Jul. doi: 10.15585/mmwr.mm6529e2). The CDC advises couples in which a woman is pregnant to use barriers methods or abstain from sex for the duration of the pregnancy. For couples not planning pregnancy and in which there is a male partner with confirmed Zika virus infection or symptoms of infection, the men should use barrier methods or abstain from sex for at least 6 months after the onset of illness. For women with Zika virus infection, they should use barrier protection or abstain from sex for at least 8 weeks after the onset of illness.
Updated guidelines released by the Centers for Disease Control and Prevention outline how to diagnose suspected cases of Zika virus infection among pregnant women based on how quickly they present with symptoms.
The guidance was updated in light of “the emerging data indicating that Zika virus RNA can be detected for prolonged periods in some pregnant women,” the CDC wrote in the July 25 issue of the Morbidity and Mortality Weekly Report (doi: 10.15585/mmwr.mm6529e1).
All pregnant women should be assessed for Zika virus at each of their prenatal care visits, regardless of their recent travel history or exposure to mosquitoes, by being evaluated for signs and symptoms of infection, such as fever, rash, and arthralgia. From there, management can take one of two directions.
The first direction involves women who are tested within 2 weeks of either symptom onset, or their suspected exposure to the virus. Pregnant women who are asymptomatic and do not live in an area with an ongoing Zika virus outbreak, as well as women who are symptomatic, should have their serum and urine analyzed using a real-time reverse transcription–polymerase chain reaction (rRT-PCR) test. If the result of this test is positive, it should be considered as confirmation that the woman has a “recent Zika virus infection.”
However, if the test results are negative, symptomatic women should undergo immunoglobin M testing for both Zika virus and dengue virus, while asymptomatic women should undergo just Zika virus IgM testing within 2-12 weeks of the possible exposure. In either case, if the tests come back negative, then the patient can be definitively cleared of any recent Zika virus infection. However, if either the Zika virus or dengue virus tests are positive or equivocal, then there is a “presumptive recent Zika virus or dengue virus or Flavivirus infection” in the woman, at which point plaque reduction neutralization testing (PRNT) must be conducted.
The second direction for management involves pregnant women who are initially tested within 2-12 weeks of either symptom onset or suspected exposure to the virus. Asymptomatic women who do not live in an area with active Zika virus transmission, or do live in an area with ongoing Zika virus cases but are already in the first or second trimester of their pregnancy – along with any women who are symptomatic – should have their serum analyzed through IgM testing for both Zika virus and dengue virus.
If both results are negative, then there is no Zika virus infection. If the Zika virus test is negative but the dengue virus test is either positive or equivocal, the woman has a “presumptive dengue virus infection” and should undergo PRNT. If the Zika virus test is either positive or equivocal, then the woman has a “presumptive recent Zika virus or Flavivirus infection,” regardless of the dengue virus IgM result. In the latter case, the next step is to conduct a reflex Zika virus rRT-PCR test on both serum and urine. A negative result on the serum test should be followed by PRNT; a positive result should be taken as proof of a “recent Zika virus infection.”
For any diagnostic chain that ends with a PRNT, the results of that test can be interpreted in one of three ways. If the Zika virus PRNT result is at least 10 and the dengue virus result is less than 10, then there is a recent Zika virus infection. If both the Zika virus and dengue virus PRNT results are 10 or greater, than there is a Flavivirus infection, but the specific one cannot be determined. Finally, if both results are less than 10, then there is no evidence of a recent Zika virus infection.
“For symptomatic and asymptomatic pregnant women with possible Zika virus exposure who seek care [more than] 12 weeks after symptom onset or possible exposure, IgM antibody testing might be considered,” the CDC wrote. “If fetal abnormalities are present, rRT-PCR testing should also be performed on maternal serum and urine [but] a negative IgM antibody test or rRT-PCR result [more than] 12 weeks after symptom onset or possible exposure does not rule out recent Zika virus infection.”
For pregnant women with a diagnosis of a confirmed or presumptive Flavivirus infection, regardless of whether it’s specifically Zika virus or not, the CDC recommends getting serial ultrasounds every 3-4 weeks during pregnancy in order to monitor the fetus’s development, while “decisions regarding amniocentesis should be individualized for each clinical circumstance.” After the child’s birth, rRT-PCR should be conducted on the child’s cord blood and serum; Zika virus and dengue virus IgM are also recommended.
Pregnant women without a diagnosis of either Zika virus or dengue virus should have a prenatal ultrasound; if abnormalities are found in the fetus, CDC recommends that they have a repeat Zika virus rRT-PCR and IgM test and that clinicians base management on corresponding laboratory results. If nothing is found, however, then standard care can resume with ongoing vigilance to avoid Zika virus infections. Women with dengue virus diagnoses should follow the guidance that is currently in place.
“Pregnant women with laboratory evidence of confirmed or possible Zika virus infection who experience a fetal loss or stillbirth should be offered pathology testing for Zika virus infection,” the CDC added. “This testing might provide insight into the etiology of the fetal loss, which could inform a woman’s future pregnancy planning.”
The CDC also issued updated guidance for preventing sexual transmission of Zika virus and that applies to all men and women who have traveled to or reside in areas with active Zika virus transmission and their sex partners (MMWR. ePub: 2016 25 Jul. doi: 10.15585/mmwr.mm6529e2). The CDC advises couples in which a woman is pregnant to use barriers methods or abstain from sex for the duration of the pregnancy. For couples not planning pregnancy and in which there is a male partner with confirmed Zika virus infection or symptoms of infection, the men should use barrier methods or abstain from sex for at least 6 months after the onset of illness. For women with Zika virus infection, they should use barrier protection or abstain from sex for at least 8 weeks after the onset of illness.
FROM MMWR
CDC: Infants with Zika symptoms should get specialized care
Diagnostic testing of infants with suspected congenital Zika virus should include both immunoglobulin M (IgM) and polymerase chain reaction (PCR) testing, according to initial recommendations from a work group of federal health officials and pediatric specialists.
The group also called for infants with Zika virus symptoms to be transferred to facilities with pediatric subspecialty services.
Officials at the Centers for Disease Control and Prevention, along with pediatric specialists, reviewed the CDC’s existing guidelines for diagnosing, treating, and preventing Zika virus infections in both pregnant mothers and their infants during a 2-day meeting at the agency’s headquarters in Atlanta July 21-22.
“We want to make sure in the evaluation of symptomatic infants that we’re opening up a thorough differential, and that people are thinking about other things, particularly as we know that some of these issues, especially in terms of diagnosis, may be complex,” said Wanda D. Barfield, MD, director of the division of reproductive health at the CDC’s National Center for Chronic Disease Prevention and Health Promotion.
Although final recommendations are forthcoming, the consensus of the work group is that diagnostic testing of infants with suspected congenital Zika virus infection should include IgM and PCR testing of cerebrospinal fluid, urine, saliva and other infant specimens.
Asymptomatic infants should continue to receive care consistent with that of a normal, newborn infant, along with comprehensive physical exams, hearing tests, and head ultrasounds.
Symptomatic infants, however, should undergo different clinical and laboratory evaluations. Any symptomatic infant should be transferred to a pediatric subspecialty facility, which would allow for more specific care and services than would a primary care office. These services would include: neonatal/pediatric intensive care; endocrinologists to treat hypothyroidism, hypoaldosteronism, and growth hormone deficiency; orthopedists to treat arthrogryposis; neurologists to perform neuroimaging and EEGs, and to treat microcephaly and seizures; and other specialists to handle infectious disease, pulmonology, genetics, and feeding issues. These facilities would also offer family and social support, including palliative care options.
Infants with anomalies associated with congenital Zika virus infection should see a primary care physician every month for “routine care and increased surveillance,” said Janet Cragan, MD, of the CDC’s National Center on Birth Defects and Developmental Disorders. These visits should include measurements of weight, length, and head circumference, and should continue through 6 months of age. After that, the frequency of visits can be reevaluated.
During subsequent visits, providers should continue to monitor the infant’s development, as certain abnormalities take longer to become evident. These include sleep issues, excessive irritability, seizures, and “subtle symptoms” such as infantile spasms.
“In terms of coordination of care, there was discussion about the need to close the loop [to] ensure that the needed testing and consultations are done, [and] that the primary physician obtain those results,” Dr. Cragan said.
Similar monitoring – though less complex and stringent – should be done for children with congenital Zika virus infection who do not exhibit abnormalities and may not be symptomatic, the work group recommended. In addition, outpatient care is another critical component in managing congenital Zika virus infections, particularly in children who display no abnormalities at birth. Specifically, hearing evaluations should be performed regularly, and if any abnormalities are found, children should be referred for repeat hearing evaluations.
“We’re talking about a group of infants that we have very little to no information about,” said Kate Russell, MD, of Duke University, Durham, N.C. “Our discussion revolved around what’s known about infants who do have apparent abnormalities and are symptomatic, and trying to infer from that what could be done for these infants with asymptomatic infections.”
Telemedicine is another potentially powerful tool that physicians can use, “particularly in areas where there is limited direct access to pediatric subspecialty care,” Dr. Cragan said. Examples include taking videos of an infant and sending them to a neurologist to determine if symptoms were consistent with Zika, or sharing audio of the crying of Zika-infected children in Brazil so that primary care physicians can compare that with their patients.
“This is an area of very new and growing research and literature, and so this is going to be a continuous process [to] make sure that the people who are going to be seeing these infants on the front line are aware of what’s known,” Dr. Russell said.
Diagnostic testing of infants with suspected congenital Zika virus should include both immunoglobulin M (IgM) and polymerase chain reaction (PCR) testing, according to initial recommendations from a work group of federal health officials and pediatric specialists.
The group also called for infants with Zika virus symptoms to be transferred to facilities with pediatric subspecialty services.
Officials at the Centers for Disease Control and Prevention, along with pediatric specialists, reviewed the CDC’s existing guidelines for diagnosing, treating, and preventing Zika virus infections in both pregnant mothers and their infants during a 2-day meeting at the agency’s headquarters in Atlanta July 21-22.
“We want to make sure in the evaluation of symptomatic infants that we’re opening up a thorough differential, and that people are thinking about other things, particularly as we know that some of these issues, especially in terms of diagnosis, may be complex,” said Wanda D. Barfield, MD, director of the division of reproductive health at the CDC’s National Center for Chronic Disease Prevention and Health Promotion.
Although final recommendations are forthcoming, the consensus of the work group is that diagnostic testing of infants with suspected congenital Zika virus infection should include IgM and PCR testing of cerebrospinal fluid, urine, saliva and other infant specimens.
Asymptomatic infants should continue to receive care consistent with that of a normal, newborn infant, along with comprehensive physical exams, hearing tests, and head ultrasounds.
Symptomatic infants, however, should undergo different clinical and laboratory evaluations. Any symptomatic infant should be transferred to a pediatric subspecialty facility, which would allow for more specific care and services than would a primary care office. These services would include: neonatal/pediatric intensive care; endocrinologists to treat hypothyroidism, hypoaldosteronism, and growth hormone deficiency; orthopedists to treat arthrogryposis; neurologists to perform neuroimaging and EEGs, and to treat microcephaly and seizures; and other specialists to handle infectious disease, pulmonology, genetics, and feeding issues. These facilities would also offer family and social support, including palliative care options.
Infants with anomalies associated with congenital Zika virus infection should see a primary care physician every month for “routine care and increased surveillance,” said Janet Cragan, MD, of the CDC’s National Center on Birth Defects and Developmental Disorders. These visits should include measurements of weight, length, and head circumference, and should continue through 6 months of age. After that, the frequency of visits can be reevaluated.
During subsequent visits, providers should continue to monitor the infant’s development, as certain abnormalities take longer to become evident. These include sleep issues, excessive irritability, seizures, and “subtle symptoms” such as infantile spasms.
“In terms of coordination of care, there was discussion about the need to close the loop [to] ensure that the needed testing and consultations are done, [and] that the primary physician obtain those results,” Dr. Cragan said.
Similar monitoring – though less complex and stringent – should be done for children with congenital Zika virus infection who do not exhibit abnormalities and may not be symptomatic, the work group recommended. In addition, outpatient care is another critical component in managing congenital Zika virus infections, particularly in children who display no abnormalities at birth. Specifically, hearing evaluations should be performed regularly, and if any abnormalities are found, children should be referred for repeat hearing evaluations.
“We’re talking about a group of infants that we have very little to no information about,” said Kate Russell, MD, of Duke University, Durham, N.C. “Our discussion revolved around what’s known about infants who do have apparent abnormalities and are symptomatic, and trying to infer from that what could be done for these infants with asymptomatic infections.”
Telemedicine is another potentially powerful tool that physicians can use, “particularly in areas where there is limited direct access to pediatric subspecialty care,” Dr. Cragan said. Examples include taking videos of an infant and sending them to a neurologist to determine if symptoms were consistent with Zika, or sharing audio of the crying of Zika-infected children in Brazil so that primary care physicians can compare that with their patients.
“This is an area of very new and growing research and literature, and so this is going to be a continuous process [to] make sure that the people who are going to be seeing these infants on the front line are aware of what’s known,” Dr. Russell said.
Diagnostic testing of infants with suspected congenital Zika virus should include both immunoglobulin M (IgM) and polymerase chain reaction (PCR) testing, according to initial recommendations from a work group of federal health officials and pediatric specialists.
The group also called for infants with Zika virus symptoms to be transferred to facilities with pediatric subspecialty services.
Officials at the Centers for Disease Control and Prevention, along with pediatric specialists, reviewed the CDC’s existing guidelines for diagnosing, treating, and preventing Zika virus infections in both pregnant mothers and their infants during a 2-day meeting at the agency’s headquarters in Atlanta July 21-22.
“We want to make sure in the evaluation of symptomatic infants that we’re opening up a thorough differential, and that people are thinking about other things, particularly as we know that some of these issues, especially in terms of diagnosis, may be complex,” said Wanda D. Barfield, MD, director of the division of reproductive health at the CDC’s National Center for Chronic Disease Prevention and Health Promotion.
Although final recommendations are forthcoming, the consensus of the work group is that diagnostic testing of infants with suspected congenital Zika virus infection should include IgM and PCR testing of cerebrospinal fluid, urine, saliva and other infant specimens.
Asymptomatic infants should continue to receive care consistent with that of a normal, newborn infant, along with comprehensive physical exams, hearing tests, and head ultrasounds.
Symptomatic infants, however, should undergo different clinical and laboratory evaluations. Any symptomatic infant should be transferred to a pediatric subspecialty facility, which would allow for more specific care and services than would a primary care office. These services would include: neonatal/pediatric intensive care; endocrinologists to treat hypothyroidism, hypoaldosteronism, and growth hormone deficiency; orthopedists to treat arthrogryposis; neurologists to perform neuroimaging and EEGs, and to treat microcephaly and seizures; and other specialists to handle infectious disease, pulmonology, genetics, and feeding issues. These facilities would also offer family and social support, including palliative care options.
Infants with anomalies associated with congenital Zika virus infection should see a primary care physician every month for “routine care and increased surveillance,” said Janet Cragan, MD, of the CDC’s National Center on Birth Defects and Developmental Disorders. These visits should include measurements of weight, length, and head circumference, and should continue through 6 months of age. After that, the frequency of visits can be reevaluated.
During subsequent visits, providers should continue to monitor the infant’s development, as certain abnormalities take longer to become evident. These include sleep issues, excessive irritability, seizures, and “subtle symptoms” such as infantile spasms.
“In terms of coordination of care, there was discussion about the need to close the loop [to] ensure that the needed testing and consultations are done, [and] that the primary physician obtain those results,” Dr. Cragan said.
Similar monitoring – though less complex and stringent – should be done for children with congenital Zika virus infection who do not exhibit abnormalities and may not be symptomatic, the work group recommended. In addition, outpatient care is another critical component in managing congenital Zika virus infections, particularly in children who display no abnormalities at birth. Specifically, hearing evaluations should be performed regularly, and if any abnormalities are found, children should be referred for repeat hearing evaluations.
“We’re talking about a group of infants that we have very little to no information about,” said Kate Russell, MD, of Duke University, Durham, N.C. “Our discussion revolved around what’s known about infants who do have apparent abnormalities and are symptomatic, and trying to infer from that what could be done for these infants with asymptomatic infections.”
Telemedicine is another potentially powerful tool that physicians can use, “particularly in areas where there is limited direct access to pediatric subspecialty care,” Dr. Cragan said. Examples include taking videos of an infant and sending them to a neurologist to determine if symptoms were consistent with Zika, or sharing audio of the crying of Zika-infected children in Brazil so that primary care physicians can compare that with their patients.
“This is an area of very new and growing research and literature, and so this is going to be a continuous process [to] make sure that the people who are going to be seeing these infants on the front line are aware of what’s known,” Dr. Russell said.
CDC reports three new cases of Zika-related birth defects
Three new cases of infants born with Zika virus–related birth defects were reported in the United States for the week ending July 14, 2016, along with 129 new infections in pregnant women, according to the Centers for Disease Control and Prevention.
The three infants were born in the 50 states and the District of Columbia, with no new pregnancy losses reported in the states or U.S. territories. Totals for the year are 12 infants with birth defects, all in the states, and seven pregnancy losses, of which six occurred in the states, the CDC reported July 21. State- or territorial-level data are not being reported to protect the privacy of affected women and children.
Of the 129 new infections in pregnant women for the week, 54 occurred in the states and 75 occurred in the U.S. territories. Those new cases bring the U.S. total to 778 for the year: 400 in the states and 378 in territories, the CDC also reported on July 21.
The figures for states, territories, and the District of Columbia reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
Three new cases of infants born with Zika virus–related birth defects were reported in the United States for the week ending July 14, 2016, along with 129 new infections in pregnant women, according to the Centers for Disease Control and Prevention.
The three infants were born in the 50 states and the District of Columbia, with no new pregnancy losses reported in the states or U.S. territories. Totals for the year are 12 infants with birth defects, all in the states, and seven pregnancy losses, of which six occurred in the states, the CDC reported July 21. State- or territorial-level data are not being reported to protect the privacy of affected women and children.
Of the 129 new infections in pregnant women for the week, 54 occurred in the states and 75 occurred in the U.S. territories. Those new cases bring the U.S. total to 778 for the year: 400 in the states and 378 in territories, the CDC also reported on July 21.
The figures for states, territories, and the District of Columbia reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
Three new cases of infants born with Zika virus–related birth defects were reported in the United States for the week ending July 14, 2016, along with 129 new infections in pregnant women, according to the Centers for Disease Control and Prevention.
The three infants were born in the 50 states and the District of Columbia, with no new pregnancy losses reported in the states or U.S. territories. Totals for the year are 12 infants with birth defects, all in the states, and seven pregnancy losses, of which six occurred in the states, the CDC reported July 21. State- or territorial-level data are not being reported to protect the privacy of affected women and children.
Of the 129 new infections in pregnant women for the week, 54 occurred in the states and 75 occurred in the U.S. territories. Those new cases bring the U.S. total to 778 for the year: 400 in the states and 378 in territories, the CDC also reported on July 21.
The figures for states, territories, and the District of Columbia reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
